Contents List of Figures vii List of Tables viii List of Charts ix Notes on Contributors x Acknowledgements xii Introduction xiv A Guide to the Book xvii Part I Nursing Skills and Concepts 1 1 Managing Nursing Care 2 RICHARD HOGSTOn 2 Social Behaviour and Professional Interactions 22 PHIL RUSSELL 3 Challenges to Professional Practice 46 STEVE TEE 4 Developing Skills for Reflective Practice 70 MELANIE JASPER Part II Nursing Interventions 93 5 Infection Control 94 SOMDUTH PArbOTEEAH 6 Administration of Medications 104 SOMDUTH PArbOTEEAH 7 Eating and Drinking 137 SUE M. GrEEN 8 Elimination 162 BArbARA A. MArjORAM 9 Respiration 194 JAN DEAN, PAMELA DIGGENS AND ROB HAYWOOD v vi CONTENTS 10 Circulation 216 CHRIS WALKER 11 Wound Management 238 PAM JACKSON, LYnn TAYLOR AND NADIA CHAMBERS 12 Moving and Handling 267 WAYNE ArnETT AND KEVIN HUMPHRYS 13 Dying, Death and Spirituality 291 PHIL RUSSELL 14 Drug and Alcohol Misuse 319 AnITA GrEEN Part III Professional Issues 347 15 Body Image and Sexuality 348 SID CARTER AND AnITA GrEEN 16 Genetics Knowledge within an Ethical Framework 369 DELIA POGSON 17 Nursing Practice in an Interprofessional Context 392 JANET McCRAY 18 Public Health in Nursing 413 ELIZABETH PORTER 19 Health Informatics 440 ADAM KEEN AND NEIL HOSKER 20 Developing Effective Leadership and Management Skills 466 YVETTE COX 21 Answers to Test Yourself! Questions 491 Index 499 Chapter RICHARD HOGSTON 1 Managing Nursing Care Contents • What is the Nursing Process? • Stage 5: Evaluation • Stage 1: Assessment • Information Technology and • Stage 2: Nursing Diagnosis Care-planning • Stage 3: Planning Nursing Care • Chapter Summary • Stage 4: Implementation • Test Yourself! • Managing Nursing Care in the • References Clinical Environment Learning outcomes The purpose of this chapter is to explore how nurses manage care; it will take you through a five-stage problem-solving approach known as the nursing process. At the end of the chapter, you should be able to: • Define the stages of the nursing process • Undertake a nursing assessment • Identify nursing diagnoses from the assessment data • Devise and implement a plan of care • Evaluate your actions • Consider the link between evaluation and quality of care. Throughout the chapter, a working example using a client who is experiencing pain will be used to demonstrate how each of the stages of the nursing process is applied. The chapter also provides an opportunity for you to undertake some exercises that will assist you with your care-planning skills. 2 MANAGING NURSING CARE 3 What Is the Nursing Process? The nursing process is a problem-solving framework that enables the nurse to nursing process plan care for a client on an individual basis. The nursing process is not under- a five-stage problem- taken once only, because the client’s needs frequently change and the nurse must solving framework enabling the nurse to respond appropriately. It is thus a cyclical process consisting of the five stages plan individualised care shown in Figure 1.1. for a client The nurse is an autonomous practitioner whose responsibilities are now governed by The Code: Standards Assessment of Conduct, Performance and Ethics for Nurses and Midwives, devised by the Nursing and Midwifery Council (NMC, 2008). This requires nurses to be accountable for Evaluation Diagnosis the care that they prescribe and deliver and to ‘keep clear and accurate records of the discussions [they] have, the assessments [they] make’ (NMC, 2008). Today, one’s ability to use the nursing process is governed by the stand- ards for pre-registration nursing education (NMC, 2010) Implementation Planning as outlined by the statutory body, the NMC, and embed- ded in parliamentary statute (DoH, 2000). The standards Figure 1.1 The nursing process state that conditional to registration is the ability to: Make a holistic person centred and systematic assessment of physical, emotional, psychological, social, cultural and spiritual needs, including risk and develops a comprehensive personalised plan of nursing care. (NMC, 2010) Failure to keep a record of nursing care or to use the nursing process can lead to a breakdown in the quality of care that is provided. The Clothier Report (DoH, 1994), which was published following the inquiry into Beverley Allitt (the nurse who was convicted of the murder of children in a hospital in Grantham, Lincolnshire), noted how: Despite the availability of a nurse with responsibility for quality management, there were no explicit nursing standards set for ward four. In addition the nursing records were of poor quality and showed little understanding of the nursing process. High Quality Care for All (Darzi, 2008) states that clinicians’ first and primary duty will always be their clinical practice or service, delivering high quality care to patients based on patients’ individual needs. Therefore, the importance of understanding and using a systematic patient-centred approach (such as the nursing process) to the provision of nursing care cannot be overestimated. There has been some debate within the profession over the number of stages nursing diagnosis needed in the nursing process, some suggesting four and others five. With a the second stage of the four-stage approach, the nurse does not have time to reflect on the assessment nursing process, often data that have been collected and instead moves from assessment to planning. described as a ‘nursing problem’, for which the The five-stage process enables the nurse to identify the client’s nursing diagnosis nurse can independently in order to plan the appropriate care. prescribe care 4 RICHARD HOGSTON The nursing process should not be seen as a linear process: it is a dynamic and ongoing cyclical process (Figure 1.1). Assessment, for example, is not a ‘one-off’ activity but a continuous one. Take the example of the individual who is in pain – it is not enough to make a pain assessment that may warrant an intervention; the nurse then needs to make a reassessment after having evaluated whether the pain-relieving intervention has been successful. The nursing process is a problem-solving activity. Problem-solving approaches to decision-making are not unique to nursing. The medical profes- sion uses a specific format based upon an assessment of the body’s systems. A number of questions are asked in a systematic manner to enable the doctor to make a diagnosis based upon the information that has been collected. Problem- solving approaches are also taken outside the health-care field. Car mechanics undertake a sequence of activities in order to diagnose what is wrong with your car when you tell them that there is a squeak or a rattle. Stage 1: Assessment Sources of assessment data Before beginning to consider what sort of information you might need to collect, P Activity 1.1 we need to look at the skills that are necessary to ensure that the data analysed Think about the client and other sources are comprehensive. Assessment is not an easy process as it includes collecting that you may be able information from a variety of sources. The quality of the assessment will, how- to consult to assist ever, depend on one’s ability to put together all the sources at one’s disposal. you when conducting a comprehensive Spend a few minutes on Activity 1.1. assessment. Write The sources that you have listed in Activity 1.1 have probably included the them down in a list. following: • Your client • Relatives, friends and significant others • Current and previous nursing records • The records of other health professionals such as doctors and physiotherapists • Statements and information from the police, ambulance personnel, witnesses at an accident scene and others. Your client The first and most important source for data collection is from the individual whom you are assessing. It will not, however, always be possible to obtain all the information you require, for a number of reasons, so you will also need to consult other people. Relatives, friends and significant others If you are assessing a baby, most of the verbal information you require will be obtained from his or her parent(s) or guardian(s). With a child, you will need to qualify some of your information through the same source. In the case of MANAGING NURSING CARE 5 an adult who is unconscious or is having difficulty breathing, you will again need to obtain data from friends, relatives, ambulance personnel, the police and so on. The same applies if the client has difficulty understanding as a result of dementia or severe learning disabilities. Nursing, medical and other records It will not always be possible to have immediate access to existing records, espe- Link cially in an emergency or with a first consultation, but these sources hold valu- Chapter 19 has more able information that you need to analyse. They provide details that may assist information on IT and prompt you. If the client has been admitted to a hospital, you may have a initiatives. letter from the GP, district nurse, health visitor or community psychiatric nurse. Similarly, on discharge from hospital, you will provide discharge information if community-based professionals need to be involved. Telephone calls to these professionals, visits and case conferences may also feature. As the roll out of the national programme for IT within the NHS occurs the use of electronic patient records should enable much faster access to a range of data (www.connecting- forhealth.nhs.uk). Skills P Activity 1.2 Spend a little while Having considered some of the sources at your disposal, we now need to think thinking about about what other factors have a bearing on a successful assessment. Spend a few what kinds of skills minutes on Activity 1.2. you need in order As we are beginning to see, the process of assessment is a complex one.